ALCOHOL USE LITERATURE REVIEW

Transcription

1 ALCOHOL USE LITERATURE REVIEW PREPARED FOR SOUL CITY BY:- Prof. Melvyn Freeman Prof Charles Parry February 2006 Contact details. Melvyn Freeman Charles Parry Tel: Tel: Fax: Fax Cel:

2 INTRODUCTION Alcohol is a complex health and social issue. There is little doubt that considerable harm is done through its abuse - even the alcohol industry accepts this - but in moderation drinking alcohol is an acceptable convention utilized by over 2 billion people word-wide. While it is possible, even probable, that if alcohol was discovered now it would be banned, prohibition is not on the agenda in South Africa or in most other parts of the world (Muslim dominated countries being the exception). The critical issue then is how does one effectively prevent and control its abuse and minimize the associated harms? This review provides background to questions such as why people consume alcohol, who consumes it, how much and when. It then looks at health impacts (both through direct biological effects and non-natural mortality and morbidity) as well as social and psychological impacts. Special areas of concern in South Africa, such as Fetal Alcohol Syndrome and impacts on sexual behaviour are briefly addressed. The review then turns to outlining some of the benefits that accrue to the country from a vibrant liquor industry but also some of the social and economic costs. The review points to international best practices with regard to alcohol prevention and asks how relevant such recommendations are for South Africa? Are there also other important issues for prevention in South Africa? The controversial issue of advertising and counter advertising is then addressed. Brief examples of community based programmes in South Africa are given as well as a summary of the current response of government to alcohol abuse. Finally some barriers to prevention and control of alcohol abuse in South Africa that need to be addressed are outlined. 1) WHY IS ALCOHOL CONSUMED? Alcohol consumption has been part of human history since antiquity. There are not only numerous biblical examples and ancient myths which refer to alcohol but local oral history and archeological findings suggests that consumption has been part of African culture, rituals, tradition and custom since time immemorial. But the fact of enduring alcohol consumption and the passing down of this habit through generations does not adequately explain why alcohol is consumed. Moreover patterns of alcohol use have changed significantly over time and evidence suggests that the quantity used now is far greater than in earlier times (See pg. 4). The WHO estimates that around 2 billion people worldwide consume alcohol (WHO 2004) and there is clearly no single reason why they do or why different people drink to different extents. It is apparent though that drinking is influenced by factors such as genetics, social environment, culture, age, gender, accessibility, exposure and personality. 2

3 1.1) Common reasons why alcohol is consumed Alcohol as a social lubricant Alcohol assists people to relax, converse more easily and mix socially. It disinhibits defenses and facilitates good company. Use of alcohol in ritual Alcohol has a mystique not shared by non-alcoholic beverages and its use in traditional rituals (locally and internationally) appears to add to the aura of special occasions. Social sharing Sharing an alcoholic drink with other people promotes a bonding and a connectedness amongst consumers often not gained through sharing non-alcoholic beverages. Drinking alcohol is accepted - and even expected - behaviour There is very little public criticism of people who drink alcohol even to states of drunkenness. On the contrary, in a number of cultures and situations it is expected that one drinks even to states of drunkenness. Obvious examples would be to see in the new year or the coming of age of a young person. Drinking in many situations is simply the status quo, i.e. that s the way things are 1. Taste and quality Though an acquired taste, consumers of alcohol enjoy the taste of alcohol. Some people develop sophisticated palates for alcohol and sincerely appreciate good quality. Even traditionally made alcohol products vary in quality and demand is mediated by this. What one drinks and how one drinks it is very often an indication of culture and class. Alcohol as a reducer of stress Alcohol is often used to reduce the tension of an event impending or actual. Research suggests that drinking can reduce stress in certain people and under certain circumstances. Differences include a family history of alcoholism, personality traits, self-consciousness, cognitive functioning and gender (Sayette, 1999). Drinking as a means of dulling the pain of poverty or other hardships of life. For many people life is simply intolerable. They live in abysmal poverty or in life circumstances which produce unbearable emotional pain. Alcohol dulls that pain for as long as they are drinking. (The fact that this leads into a cycle of ongoing poverty or pain does not influence this pattern). Consumption as macho behaviour (Mainly) men consume large amounts of alcohol as an indication of their strength and manliness. Behaviours such as drinking more than anyone else or more quickly than anyone else are often regarded as admirable masculine qualities. With changing gender roles some women also prove themselves with binge drinking patterns. Consumption in youth As children are usually prohibited from drinking alcohol, youth (again mainly males) often see drinking alcohol as a state of adult behaviour to be aspired to. 1 Though there is the beginning of a culture of not drinking and driving in South Africa, this is still at a rudimentary stage. In any event most adults in South Africa are not drivers and are hence not affected by this. The sanction against drinking and driving appears to not extend to drinking and walking (which is the cause of a significant number of road deaths) nor usually to drinking in situations where other social ills such as violence might arise 3

4 Enjoyment of a state of intoxication Many people simply enjoy the feeling of intoxication (from fairly mild to motherless ). Maintaining a state of inebriation The state of inebriation is not maintained unless additional alcohol is consumed. This may lead to more consumption and to states of drunkenness not necessarily intended when starting to drink. Lack of information Many people are ignorant of the facts regarding the impacts and effects of alcohol and drink without knowing the dangers. Counter advertising and education around alcohol in schools are limited (though see section 8.1 regarding the minimal evidence of the effectiveness of this). 1.2)Pressure to consume alcohol Responding to peer pressure. Many people, especially youth, may be, or feel, pressurized to drink alcohol as this is regarded as the social norm or the norm of a particular age or social/cultural grouping. The pressure to conform, especially amongst youth, is a well-documented psychological phenomenon. People may be (or fear they may be) excluded from or ostracized by the group if they do not partake in alcohol. Pressure from advertising/following role-models While the alcohol industry claims that alcohol advertising is aimed solely at brand switching and that it is not aimed at promoting additional consumption - especially drinking amongst youth - evidence suggests that advertising does indeed increase consumption (Snyder 2006). The association of role models depicted in adverts such as sportspeople, attractive people, strong people, outdoor people, people who enjoy life, people with superior tastes etc, etc encourage drinking behaviour in the belief that emulating this behaviour makes one more like these models. 1.3)Alcohol as part of social control Since the arrival of European settlers in South Africa, alcohol was used as a form of social and economic control. At different periods it was used in barter for cattle, in exchange for labour (including the dop system), the education of slaves and played a pivotal role in managing labour in certain sectors of the economy such as mining and agriculture (Parry and Bennetts 1998). The history of alcohol in South Africa is an integral part of the history of apartheid and segregation. During apartheid who was allowed to buy liquor, when, what types and where were all determined by race and used to control the movements, social habits and freedoms of black people. In townships, municipal beer halls were established by local authorities to help finance township development and control the behaviour of black people. In response, many people turned to illegal liquor related activities - both brewing traditional African beer and setting up illegal outlets (shebeens) where liquor was sold. Importantly the growth of illegal shebeens in the second part of the 20 th century served not only as a way to increase access to alcohol, as a means for social mixing and as employment for the owners and employees but also as a form of resistance to apartheid policies. Moreover during the 1976 uprisings in Soweto and other 4

5 townships, beerhalls were specifically targeted as they had come to symbolize white domination and control. This history of distribution, consumption and resistance is critical for understanding current alcohol related behaviour 1.4)Alcohol dependence The reasons why most people drink can probably be found in a combination of the above factors, however for some people, drinking is allied with a disease - alcohol dependence. This disease is characterized by craving, a strong need or compulsion to drink; impaired control, the inability to limit one s drinking on any given occasion; physical dependence, withdrawal symptoms such as nausea, sweating and anxiety when alcohol use is stopped after a period of heavy drinking; tolerance, the need for increasing amounts of alcohol in order to feel its effects. It is a chronic and often progressive disease. People need to drink despite negative consequences such as serious job or health problems. It is influenced by both genetic and environmental factors. 2) WHO CONSUMES ALCOHOL IN SOUTH AFRICA, HOW MUCH AND WHEN? Though alcohol has been consumed for thousands of years, the quantity and patterns of alcohol consumption have changed significantly over the past 500 years. The most important of these changes has been the replacement (or in some instances complementing) of traditional and locally produced beverages with industrial beverages in particular Western-style commercially produced beer (Riley and Marshall, 1999). As a result of this, regular heavy drinking has become a sustainable pattern. Previously alcohol products did not last long especially in warm climates and each batch was consumed within a relatively short period of time. The amount of alcohol available was typically limited by the amount of agricultural surplus (Room et al. 2002). Other factors which have substantially affected patters of drinking in developing countries include urbanization, changes in gender and age roles, and high intensity mass marketing and promotion of alcoholic beverages by mass multinational corporations. (Parry 2000). In traditional African society the use of alcoholic beverages appears to have been well regulated. Drinking did not occur on a daily basis and people did not drink alone or just for the sake of drinking. Rather, drinking served a communal and ceremonial purpose (Western Cape Department of Economic Affairs and Tourism, 2003). However this changed with the social and economic developments mentioned. Life for black people tended to be extremely hard and many people turned to drink to alleviate their stress and sorrow. Rates of drinking in countries with the highest consumption are decreasing while the opposite is true of countries with lower consumption (corresponding generally to more developed vs. less developed countries). It also appears that there is a link between economic prosperity and rising alcohol consumption (e.g. Ireland and the Nordic Countries). 5

6 Recorded consumption Data on country level alcohol consumption is usually measured in terms of recorded alcohol derived from formal production and sales - the UN Food and Agriculture Organisation collects annual figures directly from governments around the world and measured in terms of per capita alcohol consumption (15+) in litres of pure alcohol. The WHO Global Status report on Alcohol 2004 reported on alcohol consumption in 189 countries (WHO 2004). Consumption ranges from Muslim countries such as Iran and Saudi Arabia were no alcohol is consumed (in terms of official production and sales) to Luxembourg and Uganda who consume and litres of pure alcohol per adult capita respectively. South Africa is the 47 th highest consumer with 7.81 litres per capita. These figures do not, however, include unrecorded consumption or the consumption of those who do not drink i.e. excluding adults who abstain from alcohol. Unrecorded consumption Unrecorded consumption includes traditionally brewed beverages (mainly brewed in villages and homes), cross border trade, smuggling, tourist consumption and beverages with alcohol below the legal definition of alcohol. Few countries have been able to estimate the level of unrecorded alcohol consumed, though some research has been done and estimates suggested. Countries in Africa with high levels of estimated unrecorded alcohol use include Kenya (5.0 litres), Swaziland (4.1 litres. Uganda (10.7 litres) and Zimbabwe (9.0 litres). South Africa was estimated to consume an additional 2.2 litres per adult capita. Total alcohol consumption is thus estimated to be around 10 litres per adult capita. Other estimates have suggested 12.4 per year Locally made beverages are usually cheaper than mass or factory based products, often brewed in rural areas and is consumed mostly by the poorer segments of society. They are also often used as part of ceremonial occasions. 2.1)Who drinks in South Africa? The adult per capita measurement of alcohol consumption assumes an average across the population, but clearly not everyone consumes equal amounts. In 1998, as part of the first South African Demographic and Health Survey (SADHS), an alcohol survey was conducted to assess the extent of alcohol use, risky drinking, and alcohol problems among South Africans in order to obtain estimates of consumption and risky drinking and to inform intervention efforts (Parry et al, 2005). The SADHS was a national household survey providing cross-sectional data on a representative sample of the non-institutionalised population. Current and life time drinking from this survey were as follows:- 6

7 Percentage of males and females (aged 15 years or older) reporting lifetime and current use of alcohol. Background characteristics Ever drunk alcohol Drink now (Current drinking) Males Females Males Females Age Geographic setting Urban Non-urban Province Western Cape Eastern Cape Northern Cape Free State KwaZulu Natal North West Gauteng Mpumalanga Northern Education # No education Gr. 1 Gr. 5 Gr. 6 Gr. 7 Gr. 8 Gr. 11 Grade 12 Higher Population group African Afr. Urban Afr. Non-urban Coloured White Asian Total Just under half the men (45%) and one-fifth of the women (17%) 15 years and older reported that they currently consume alcohol. Rates of current drinking differed substantially by population group and gender, with the highest levels reported by white males (71%), followed by white females (51%), and Coloured males (45%). The lowest rates were reported by African and Asian females (12% and 9% respectively). For both men and women higher rates of current drinking were recorded in urban areas. For males the highest current drinking levels were reported in the Free State and Gauteng (50% or more) and the lowest levels were reported in the Northern Province (28%). For females, the lowest levels were also recorded in the Northern Province (9%), with the highest levels being in the Free State, Western Cape and Northern Cape (23%-25%). For both men and women the highest levels of current alcohol use were recorded among persons in the and year age 7

8 groups, and the lowest levels in the year group. These figures are likely to be underestimates given the nature of broad household surveys, where respondents may be dishonest about behaviors which may be stigmatized or disapproved of in certain communities and where inadequate attention may be given to setting respondents at ease in asking sensitive questions (Gfroerer et al., 1997). Female drinking, in particular, is often disapproved of in many African communities and as a result is likely to be under-reported (Mphi, 1994; Siegfried et al., 2001). From this survey it is evident that those who do drink, drink heavily closer to 20.1 litres of pure alcohol per year. This is amongst the highest in the world (Rehm et al 2003). 2.2) Risky and problem drinking Table 2. Percentage of males and females (aged 15 years or older) current drinkers engaging in risky drinking Current drinkers CAGE 2 (Alcohol problems) Risky drinking - weekdays* Risky drinking - weekends* Males Females Males Females Males Females Age Geographic setting Urban Non-urban Province Western Cape Eastern Cape Northern Cape Free State KwaZulu Natal North West Gauteng Mpumalanga Northern Education # No education Gr. 1 Gr. 5 Gr. 6 Gr. 7 Gr. 8 Gr. 11 Grade 12 Higher Population group African Afr. Urban Afr. Non-urban Coloured White Asian Total

9 Risky drinking was defined as drinking five or more standard drinks per day for men and three or more drinks per day for women. Many people that do drink tend to binge especially over weekends. Rates of risky drinking amongst current drinkers were very similar for male and female drinkers (remembering that far more males are drinkers) and were approximately 4-5 times greater at weekends than on weekdays, with one-third of current drinkers drinking at risky levels over weekends (Males 33%; Females 32%). For both males and females, risky drinking at weekends appeared to be highest among persons in the middle categories for age (35-44 years for males and years for females), among persons residing in non-urban areas, with a low level of education (grade 1 to grade 7), and amongst Coloureds and Africans. Weekend risky drinking by males appeared to be highest in Mpumalanga, whereas for females the highest levels appeared to be in the Northern Cape. The screen for symptoms of alcohol problems (CAGE) found that overall almost a third of males reported symptoms of alcohol problems. This translated to almost two thirds of those who reported currently drinking alcohol. The proportion for females overall was significantly lower. However, when considering the current female drinkers, the proportion who scored two or more on the CAGE screen was virtually equal to that of the males. The apparent relationship between socio-economic status and an increased risk for alcohol-related problems, with wealthier persons having lower levels of alcohol problems, is confirmed by international studies (Khan et al., 2002). For example, a study conducted in Nepal (Jhingan et al., 2003) also found that lower levels of education were linked to higher scores on the CAGE Questionnaire and that symptoms of alcohol problems seemed to peak in the older age groups (45-54 years for both genders in the Nepal study, versus years for males and years for females in this study). The rates of current drinkers found in this survey were lower than those reported for other developing countries, including Mexico (males 77%, females 44%), Chile (males 77%, females 44%), Thailand (males 71%, females 46%), and Namibia (males 61%, females 47%) (Room et al., 2002). Although risky drinking was fairly uncommon during weekdays, it increased significantly over weekends, coinciding with findings from other developing countries, such as Zimbabwe (Room et al., 2002). Interestingly, male and female drinkers were equally likely to engage in risky drinking over weekends, which does not appear to be the case in other developing countries (Room et al., 2002). In most other developing countries males are more likely to engage in risky drinking than females. The similarly high levels of risky drinking between males and females found in this study also differs from that found in most developed countries where levels of risky drinking are much higher among males (Babor et al., 2003). 9

10 Harmful drinking patterns amongst South Africans was also reported in the 2002 World Health Report (WHO, 2002) where South Africa fell into the group of countries exhibiting the most harmful pattern of drinking )What do people drink? By far the largest quantity of alcohol consumed is beer, followed by African traditional Beer, wine, brandy, other spirits, alcoholic fruit beverages, whisky, fortified wine and sparkling wine. Beer Trad beer Wine Brandy Other spirits Alco Fruit bev Whisky Fortified wine Spark wine % 24.7% 12.3% 6.5% 4.4% 3.4% 2.7% 2.4% % Tot 2.5)Alcohol consumption in Youth There have been few studies that have documented prevalence rates of substance abuse amongst young people in South Africa. In 1990 Rocha-Silva et al (1996) found that 34% of black youth aged had used alcohol in the previous 12 months. In 1993 Flisher et al found that 27% of school going youth had engaged in binge drinking in schools in the Cape Town. A later study by Flisher et al (2003) found:- Life Time Past year Past month Grade 8 Grade 11 Black Coloured White Black Coloured White Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls An important finding of this study was that black female adolescents consumed significantly less alcohol than either their male counterparts of females of other races. Another important finding was that the numbers of days absent from school correlated with alcohol use. Whether this is a causal relationship or related to another variable such as unconventionality (ie the same people tend to more rebellious type behaviours due to personality of other factors) cannot be gleaned from this study. A community survey in Cape Town in 2002 found that more than 10% of 11- to 17- year olds had been drunk more than 10 times. The median age of first use of alcohol was 14 years. Adolescents who reported having been drunk were more likely to live in communities where youth have easy access to alcohol and where they are exposed to public drunkenness. Older adolescents and adolescents whose friends drink were more likely to have been drunk at least once. Risks of having been drunk were being white and being exposed to public drunkenness on a daily or at least weekly basis. 2 Harmful drinking was indicated by the level of the population drinking first thing in the morning, drinking to intoxication, drinking apart from meals etc. 10

11 Attendance at religious services was found to be a significant protective factor against drunkenness. In the 2002 National Youth Risk Behaviour Survey half of learners (49.1%) between grades 8 and 11 had drunk at least one drink of alcohol in their lifetime. In the 30 days preceding the survey 31.3% used alcohol on one or more days while 23% reported binge drinking (five or more drinks within the space of a few hours) on one or more days (29% of males and 18% of females). Significantly higher percentages of white and coloured learners had ever drunk alcohol. Rates of using alcohol (including binge drinking) increased with age and grade. Comparisons of data across different studies suggests that over time there has been an increase in the proportion of people drinking amongst South Africans with particular increases among young, black African males and females. 3)HEALTH IMPACTS OF ALCOHOL In 2000 alcohol was responsible for 4% of the global burden of disease more or less equal to the damage caused to society by tobacco use (4.1%). Alcohol was estimated to have caused 1.8 million deaths, or 3.2% of all deaths globally. Contribution to the global burden of disease was considerably higher in developed (9.2%) than developing countries, in part due to the greater consumption of alcohol in these countries and in part due to the high burden from other diseases in developing countries (such as AIDS, Malaria, childhood illnesses etc). Alcohol consumption contributes to disease, injury, disability and premature death more than any other risk factor in developing countries with low mortality, where alcohol is responsible for 6.2% of disability adjusted life years lost. In high mortality regions including Afro Region E the GBD was calculated to be 1.6%. For South Africa the estimated burden due to alcohol (death and disability) has been calculated to be 7.0%, 10.5% for males and 3.1% for females (Schneider et al., personal communication). Moreover there are many other negative consequences of alcohol that are not taken into account in analysing global burden of disease, such as the effects on families, communities and society as a whole. 3.1)Direct biological Impacts Both acute intoxication and chronic/long term excessive drinking may have adverse effects on the brain, central nervous and muscular system, liver, heart (though there are also some positive effects for certain groups of people), blood cells, gastrointestinal system, respiratory system, reproductive system as well as the immune system. Its use contributes to more than 60 diseases and conditions. The following conditions are some of the most important. The prevalence rates of most of these diseases in South Africa is generally not known and unless specifically stated rates refer to international figures. Alcoholic liver disease Alcohol is absorbed quickly into the blood system, passes through organs where is oxidises slowly and can cause damage. The most common organ affected is the liver. 11

12 Mortality studies have consistently demonstrated that heavy drinkers die from liver disease at a much higher rate than the general population. Types of alcoholic liver disease include alcoholic fatty liver (prevalent in about 20% of heavy drinkers); alcoholic hepatitis; and alcohol cirrhosis (about 10-15% of people with alcohol dependence develop cirrhosis). Alcohol also increases the risk of developing liver cancer. Alcohol hepatitis is characterised by inflammation (necrosis) of the liver, jaundice and abdominal pain. Scar tissue may replace healthy tissue leading to a process of fibrosis. The condition is reversible with abstinence. Alcohol cirrhosis is the most advanced form of liver disease. The liver is characterised by extensive fibrosis that stiffens blood vessels and distorts the internal structure of the liver. This damage results in severe functional impairment and may result in secondary malfunction of other organs including the brain and kidneys. The amount of alcohol consumed and the duration of that consumption are closely associated with cirrhosis. Importantly, as consumption increases the risk of cirrhosis is greater for women than for men. Moreover consumption of alcohol without food results in higher risk than with food. Cirrhosis can stabilise with abstinence. While alcoholic fatty liver, alcohol hepatitis and cirrhosis have been considered to be sequentially related, i.e. progressing in this order, this is not always the case. Some cirrhosis develops without hepatitis and hepatitis may have a sudden onset and a rapid course resulting in death even before cirrhosis can develop. Effects on the heart Alcohol can be beneficial or harmful to the cardiovascular system depending on the amounts consumed and the characteristics of the consumer. Low to moderate consumption has been shown to have coronary benefits for people who are 40 years and older. However according to the WHO in some industrialised countries where the condition is common and injuries and violence are rare, alcohol consumption may prevent about as many deaths as it causes in some segments of the population. The patterns of drinking in many countries, however, often with heavy episodic consumption, are likely to increase rather than decrease the occurrence of coronary heart disease (WHO, 2005). Importantly, questions have also been raised regarding the transferability of the finding of the benefits to developing countries. As coronary heart disease is associated with diet, lifestyle and age and given that the diet of many traditional developing countries is relatively low in fat and high in fibre (a factor that is often given as one of the reasons for the comparatively low incidence of heart disease in developing countries) the findings of the protective effects may not be applicable. Moreover even if moderate drinking is protective, heavy alcohol consumption could damage the cardiovascular system causing heart muscle disorders, irregular heart rhythms, high blood pressure and strokes. 12

13 Effects on blood cells Alcohol has numerous adverse effects on blood cells and their functions. For example heavy drinking can cause generalised suppression of blood cell production and the production of abnormal blood cell precursors that cannot manufacture cells. There is evidence that blood pressure increases with increased drinking. A study in India found alcohol consumption to be a significant risk factor for hypertension. A meta-analysis found that 11% of cases of hypertension in males and 6% in females could be directly causally attributed to alcohol. Gastrointestinal and respiratory systems Alcohol can interfere with the structure and function of the gastrointestinal tract. For example alcohol can impair the muscles separating the oesophagus from the stomach increasing the risk of cancer. Alcohol interferes with the muscle movement of the small and large intestines and the absorption of nutrients into the body. Epidemiological research in developing countries has found a causal link between heavy alcohol consumption and pancreatitis. 84% of cases of chronic pancreatitis were attributable to alcohol. A meta analysis of more than 200 studies found that alcohol strongly increased the risks of various types of cancers (oral cavity, pharynx, oesophagus and larynx) and found statistically significant increases in risk for cancers such as stomach, colon, rectum, liver, breast and ovaries. Reproductive system In men alcohol can result in loss of libido, reduced potency, shrinking in size of testes and penis, reduced or absent sperm formation and so infertility. In women alcohol has been found to result in menstrual irregularities, shrinking of breast and external genitalia and sexual difficulties. It also affects female reproductive capacity. Immune system From animal and in-viro studies it is evident that alcohol impairs various aspects of the immune system and, particularly, increases the susceptibility to HIV infection. It may also interfere with adherence to anti-retroviral treatment. Some evidence also suggests that alcohol may lead to accelerated progression of the disease. Effects on the brain and central nervous system. Alcohol directly affects brain function in a number of ways. On a behavioural level neurological disorders resulting from alcohol can result in changes in emotions, personality, impaired perception, learning and memory. The detrimental effects of alcohol on the brain may be similar to Alzheimer s Disease. From autopsies it has been established that the brains of people with severe alcohol dependency are smaller, lighter and exhibit greater atrophy than non-alcoholics. Neuropsychological studies with people with chronic alcohol dependence have reported cognitive deficits including problems with problem solving, organising, planning and abstraction (frontal lobe functions); short and long term memory loss; 13

14 verbal fluency, learning, and visio-spacial perceptions. Impaired co-ordination and balance have also been found. Co-morbidity Psychiatric co-morbidity is common in individuals with a history of alcohol abuse and dependence. Schizophrenia, bi-polar disorder, depression, attention deficit disorder, anxiety disorder and eating disorders have all been associated with abuse of alcohol though it is not always clear which condition preceded which. Depression According to the WHO Global Status report on Alcohol (WHO 2004) there is now evidence to assume that alcohol has a causal role in depression. Not only do alcohol dependence and major depression co-occur disproportionately but also higher volumes of alcohol consumption are associated with more symptoms of depression. While it has often been postulated that people suffering from depression self medicate with alcohol (and in some cases this is no doubt true), the question of which precedes the other is not yet fully resolved and/or whether there may be a third variable (such as neurobiological mechanisms or genetic predisposition) which causes both to occur. Nonetheless evidence of a causal link from alcohol to depression is growing. Reversibility (remission during abstinence) is a key indicator for causal effect of alcohol dependence on depressive disorder and there is good evidence that abstinence substantially removes depressive disorders within a short time frame. Alcohol dependence The ICD-10 defines alcohol dependence syndrome as being a cluster of physiological, behavioural and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic is the desire (often strong, sometimes overpowering) or sense of compulsion to take alcohol. In the WHO Global Status Report on Alcohol 2004, of 35 countries reporting levels of alcohol dependence amongst the adult population, South Africa had the highest reported figure i.e. 27.8% of males and 9.9% of females. This should, however be interpreted with great caution as for example instruments and timeframes used were not standardised. Alcohol dependence is consistently the substance of abuse in people receiving help for substance related problems in South Africa. In the first half of 2005, between 47% (Cape Town) and 74% (Durban) of patients receiving treatment had alcohol as a primary or secondary drug of abuse (Sacendu 2005). Though the proportion of people reporting alcohol as the primary drug of abuse is decreasing as pressure on treatment slots increases from other drugs, this still remains the major cause of people receiving treatment. The proportion of patients older than 20 seeking treatment for alcohol problems is substantially higher than for younger patients. 3.2)Non-Natural Mortality And Morbidity Unintentional and intentional injuries are responsible for up to 10% of the global burden of disease. Internationally alcohol use accounts for 13% of DALYs lost due to 14

15 unintentional injuries and 15% due to intentional injuries. The amount of alcohol consumed is a major determinant of both risk and severity of injury. Alcohol plays a major role in traffic and other accidents as well homicides, interpersonal injury and suicide. High rates of alcohol have been found in both the perpetrator and the victim 3. The largest number of non-natural deaths is South Africa is due to violence (48%) followed by transport fatalities (30%). Both violence and transport deaths are closely linked with alcohol. Alcohol related mortality Data from the Non-Natural Mortality Surveillance System (NNMSS) in 2002 indicated that 46% of non-natural deaths in South Africa involved persons with blood alcohol concentrations (BACs) greater than or equal to 0.05g/100 ml (Matzopoulos et al., 2003). NNMSS data for 2003 indicated that for all causes of death, 49% had positive BACs and the mean BAC overall was 0.18g/100ml (Harris et al., 2004). Levels of BAC positivity were high for homicides (51% positive, with a mean BAC of 0.17g/100ml), suicides (35% positive, with a mean BAC of 0.15g/100ml) and transport related deaths (53.3%). The majority of transport related deaths in South Africa are of pedestrians 38.8%, followed by unspecified (21%), driver of a motor vehicle (17.7%) and passenger (12.2%) of deaths. While in all categories of transport related death, high alcohol blood levels was prevalent, this was highest amongst pedestrians (61%). This means that by far the largest number of transport related deaths in South Africa are of intoxicated pedestrians. Despite this, campaigns almost always focus on drinking and driving and not on drinking and walking! Alcohol related trauma In % of trauma patients in Cape Town, Durban and Port Elizabeth had breath alcohol concentrations (BrACs) greater than or equal to 0.05g/100 ml (Plüddemann et al., 2004). Levels of alcohol positivity were particularly high for persons injured as a result of violence (73% for Port Elizabeth, 61% for Cape Town and 43% for Durban). In data gathered from a wide variety of facilities in the Cape Metropol, Peden reported that 70% of domestic violence cases were alcohol-related (Peden, 1995). From research conducted by the Department of Transport the national daily average of persons driving under the influence of alcohol has been found to have increased from 1.8% in 2002 to 2.1% in 2003 (Arrive Alive, 2005). 3 The differences between perpetrator and victim are not always clear. For example victims may include people involved in fights who happened to be the one injured/killed or the drunk driver of a motor vehicle injured or killed in an accident. 15

16 4)SOCIAL AND PSYCHOLOGICAL IMPACTS Social and psychological impacts of alcohol are even more difficult to measure than the physical health impacts. One can, however for example, look at substantive impacts on crime, patterns of interpersonal violence and family and work problems. 4.1)Alcohol and crime A national study of prisoners and parolees in 1996 found that just under half had taken alcohol or other drugs just prior to the crime for which they were incarcerated (Rocha-Silva & Stahmer, 1996). Drinking was especially linked to rape and housebreaking offences. Subsequent research in Cape Town, Durban and Johannesburg in three phases between 1999 and 2000 (Parry et al., 2004) found that overall 15% of arrestees indicated that they were under the influence of alcohol at the time the alleged offence took place. Regarding violent offences, arrestees indicated that they were under the influence of alcohol for 25% of weapons related offences, 22% of rapes, 17% of murders, 14% of assault cases and 10% of robberies. Levels of alcohol-related crime were particularly high for family violence offences at 49%. Arrestees also indicated that they were often under the influence of alcohol in cases involving property offences, for example, 22% of cases involving housebreaking and 12% of cases involving the theft of a motor vehicle. When asked why they consumed alcohol or other drugs in relation to crimes, many arrestees indicated they consumed these substances in order to give them courage to commit the crimes (Parry et al., 2004). 4.2)Interpersonal violence. Numerous studies have found an association between alcohol consumption and aggressive behaviour though clearly not everyone who consumes alcohol gets aggressive. People with anti-social personality disorder appear to be particularly susceptible to alcohol related aggression. People who have previously been violent under the influence of alcohol are the most likely to become aggressive when drinking again. Internationally alcohol has been associated with numerous acts of interpersonal violence which include physical and sexual abuse, emotional and psychological abuse and neglect. The WHO (draft paper 2005) has identified the following 5 major areas of interpersonal violence (with examples of each). 16

17 Box 1: Alcohol and interpersonal violence Youth violence Violence committed by young people Child abuse Violence and neglect towards children by parents and carers Intimate partner violence Violence occurring within an intimate relationship Elder abuse Mistreatment or neglect of older people by family, carers or others where there is an expectation of trust Sexual violence Including sexual assault, unwanted sexual attention and sexual coercion Among year old males, those who binge drink * are more than twice as likely to have committed a violent crime in the previous year than regular but non-binge drinkers (England and Wales) Parental alcohol or drug use was reported in 34% of child welfare investigations (Canada) 71% of female victims of intimate partner violence stated partner alcohol use as the main cause of their assault, and 22% reported using alcohol following the event as a mechanism for coping (Iceland) 44% of male and 14% of female abusers of elderly parents (age 60+) were dependent on alcohol or drugs, along with 7% of victims (USA) A fifth of offenders arrested for rape reported that they were under the influence of alcohol at the time of the crime (South Africa) Alcohol consumption by perpetrators of violence In the USA, among victims that were able to report whether their attacker had been drinking alcohol, around 35% believed the offender had been drinking. In England and Wales, 50% of victims of interpersonal violence reported the perpetrator to be under the influence of alcohol at the time of assault. In Russia, more than two thirds of individuals arrested for homicide had consumed alcohol before committing the crime. In South Africa, 44% of victims of interpersonal violence believed their attacker to be under the influence of alcohol or drugs at the time of the incident. In Tianjin, China, a study of inmates found that 50% of assault offenders had been drinking alcohol prior to the incident.. 4.3)Family and work problems Drinking can impair functioning as a parent, as a spouse and as a contributor to household functioning (Mulaudzi et al 2003). Most drinking requires time (often spent with drinking colleagues) and this competes with time needed to carry on family life (e.g. time spent with children, doing household chores etc). Drinking costs money. Drinking money often takes precedence over other household needs, often leaving the family unable to afford even basic goods and services. 17

18 Drinking leads to a spiral of poverty in which the drinking behaviour inhibits income capacity (through absenteeism, lack of motivation, poor quality of work, loosing employment) while any income earned is then spent on drink at times drowning sorrows regarding not having work or only having a poorly paid job. A study in Delhi, India, compared families where the husband drank at least three times a week compared to those where the husband drank only once a month. In the first group 24% of household income was spent on alcohol compared with 2% in the other families. The family with the drinker had significantly more debts (60% vs. 42%) and these debts were twice as large (Saxena in Mulaudzi, 2003). While continuing patterns of drinking threaten family subsistence, events that take place when a family member is intoxicated can also have lasting consequences mainly through injuries and family violence. The psychological toll on the family is often great. For example in interviews with family members of heavy drinkers in Mexico 73% reported feelings of anxiety, fear and depression, 62% reported physical or verbal aggression and 31% reported family disintegration. For many mothers, the inability of the fathers to bring in adequate incomes due to their drinking habits, and therefore being unable to feed and clothe their children led to depression in the mothers (Rosovosky in Mulaudzi, 2003). Violence against women and children often has severe psychological consequences for the victim (WHO 2001). Alcohol can impair work performance through decreased efficiency and can lead to poor workplace safety. For example intoxication can result in errors of judgement, accident proneness and putting other lives at risk. Alcohol misuse also results in greater absenteeism from work and increases the risk of dismissal from work. In Costa Rica it was found that 30% of absenteeism and workplace accidents were caused by alcohol dependence. In India 15-20% of absenteeism and 40% of accidents were due to alcohol. Among grade 8 and 11 learners in Cape Town a significant association was found between past month use of alcohol and the number of days absent from school and repeating a grade. The odds of repeating a grade were 60% higher for learners who consumed alcohol. (Whether this relationship was causal, which way, or occurred through another factor was not established). 18

19 5)SPECIAL AREAS OF CONCERN IN SOUTH AFRICA Two areas regarding alcohol in South Africa need special mention. These are Fetal Alcohol Syndrome (FAS) and HIV/AIDS. 5.1) Fetal Alcohol Syndrome (FAS). Drinking alcohol during pregnancy may lead to damage to the foetus. This could be in the form of Fetal Alcohol Effects or full-blown Fetal Alcohol Syndrome. FAS is characterised primarily by damage to the brain and central nervous system which results in hyperactivity, attention problems, learning disabilities (e.g. problems of memory, abstract reasoning), lack of judgement and fits. Other organs such as the heart, kidneys and growth may also be affected. As there is no cure for FAS, as most FAS children are unable to cope with normal schooling and as many FAS children are part of alcoholic families who are unable to give them the special care and attention they need, many FAS children drop out of school early, are not easily employable and are susceptible to gangs, crime and peer-pressure. South Africa has the highest reported rate of FAS in the world. (It must be noted though that most poorer countries have never conducted epidemiological research into FAS and thus rates in these countries are not known). In poorer areas of the Western Cape prevalence of FAS among Grade 1 learners was found to be 46 per 1000 in 1997 and increased to 75 per 1000 in In the Northern Cape rates of 103 and 75 per thousand were found in different areas. Prevalence in three poor areas in Gauteng found rates of 12, 22 and 37 per While the Gauteng rates were lower than areas of the Cape they are still far higher than even the most at risk communities in developed countries - such as the urban poor or native settlement areas in the USA. In studies in the USA and France rates of 0,5 and 3,0 per 1000 were found. Mothers who drink alcohol in a binge fashion while pregnant and exceed 5 drinks per week per occasion (ie More than 90mls of absolute alcohol) are especially at risk for FAS. Thus one heavy bout of drinking may be enough to cause FAS. (FARR, 2005) 5.2)Risky sexual behaviour The misuse of alcohol is increasingly being recognized as a key determinant of sexual risk behaviour, and consequently, an indirect contributor to HIV transmission in sub- Saharan countries (e.g. Fritz et al., 2002). According to Morejele et al (2004) numerous cross-sectional investigations conducted among adults in this region have shown consistently that alcohol use is associated with HIV infection (Campbell, Williams, & Gilgen, 2002; Clift et al., 2003; Fritz et al., 2002; Hargreaves et al., 2002; Mbulaiteye et al., 2000; Mnyika et al., 1996), as well as with sexual risk behaviours, such as having multiple sexual partners (Mnyika, Klepp, Kvale, & Ole- Kingori, 1997; Trigg, Peterson, & Meekers, 1997). Three different but related explanations are proposed to account for the relationship between alcohol use and sexual risk behaviour. Firstly that alcohol consumption may represent other behavioural, lifestyle, contextual and/or personality factors which are associated with engagement in high-risk sexual behaviour (e.g. Hargreaves et al., 2002; Plant, 1990). Secondly, ethanol acts on the central nervous system, reduces 19

20 inhibitions, and consequently, increases people s likelihood of engaging in risky sexual and other behaviours (Plant, 1990). Thirdly people s alcohol expectancies (i.e. their expectations about how alcohol will influence their behaviour), can also influence their actual behaviour (Brown, Christiansen, & Goldman, 1987). In both qualitative and quantitative studies conducted by Morojele et al (2004) in a black township in South Africa amongst adults it was found that there were strong relationships between various measures of alcohol use and risky sexual behaviour. In the quantitative study two main types of effects were that alcohol consumption may have on sexual behaviour were identified; drinking seems to increase the appeal of sexual episodes and reduce people s control with respect to sexual encounters. The variables which were found to be associated with the reported increased sexual appeal due to drinking were being younger, not being married, being employed, drinking more, being a problem drinker, having more sexual partners and engaging in regretted sex. This profile seems to suggest that inexperienced, younger, heavier drinking adults are at greatest risk of having alcohol-related risky sexual encounters. Those who reported being less able to have control over their condom use after drinking were less likely to have used condoms in their lifetime. It seems that those who are usually not inclined to use condoms may become even less inclined to use them after drinking; on the other hand, other individuals who are most strongly committed to condom use become even more vigilant when drinking. Men appear to be at greater risk of engagement in alcohol use-related sexual risk behaviour than women. Men seem to be more likely to drink at all and drink larger quantities than women. They are also more likely to report that they engage in sex under the influence of alcohol, that drinking increases their desire to have sex with a casual partner and that drinking worsens their ability to resist unwanted sexual advances. 6)BENEFITS ARISING FROM THE LIQUOR INDUSTRY Despite the above there are important benefits, which accrue from the alcohol industry. The industry, through alcohol producing companies, acting independently and through the Industry Association for Responsible Alcohol Use (ARA), aim to promote the responsible use rather than the abuse of alcohol. It is argued that the majority of people who consume alcohol in South Africa do so without damaging consequences and that this trend should be encouraged. They also argue that the industry does far more good for the country than harm. Some of the contributions which the industry make (aside from the enjoyment that people get) are:- Employment creation: South African Breweries (including ABI) employs people (2005 web page). Salaries and wages amounted to around R2.2 billion. It is estimated that more then 1 million people are employed in the beer and soft drink value chain. The wine industry estimates that jobs were directly and indirectly supported by the industry in of these were directly employed. They estimate 20